Background and purpose CT Angiography (CTA) is increasingly used to evaluate non-traumatic subarachnoid hemorrhage (SAH) given its excellent sensitivity for intracranial aneurysms. We determined the yield of Digital Subtraction Angiography (DSA) among patients presenting with SAH or intraventricular hemorrhage (IVH) and a negative CTA.
Methods A 11-year, single-center retrospective review of all consecutive patients with CTA-negative SAH was performed. Non-contrast head CT, CTA, DSA, and MRI studies were reviewed by three experienced neuroradiologists and interventional neuroradiologists.
Results 230 patients (mean age 54 years, 51% male) who presented with CTA-negative SAH were identified. The pattern of SAH on presentation was diffuse (40%), perimesencaphlic (31%), sulcal (31%), isolated IVH (6%), or identified by xanthochromia (7%). Initial DSA yield was 13%, including vasculitis/vasculopathy (7%), aneurysm (5%), arteriovenous malformation (0.5%), and dural arteriovenous fistula (0.5%). An additional 6 aneurysms/pseudoaneurysms (3%) were identified by follow-up DSA, and a single cavernous malformation (0.4%) was identified by MRI. No cause of hemorrhage was identified in patients presenting with isolated IVH or xanthochromia. Diffuse SAH was due to aneurysm rupture (17%); perimesencephalic SAH was due to aneurysm rupture (3%) or vasculitis/vasculopathy (1.5%); and sulcal SAH was due to vasculitis/vasculopathy (32%), arteriovenous malformation (3%), or dural arteriovenous fistulae (3%).
Conclusions DSA identifies vascular pathology in 13% of patients with CTA-negative SAH. Aneurysms or pseudoaneurysms are identified in an additional 3% of patients by follow-up DSA following an initially negative DSA. The pattern of SAH may suggest the cause of hemorrhage, and aneurysms should be sought in patients with diffuse or perimesencephalic SAH.
Disclosures J. Heit: None. G. Pastena: None. R. Nogueira: None. A. Yoo: None. T. Leslie-Mazwi: None. J. Hirsch: None. J. Rabinov: None.
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